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Acta Scientific Women's Health
Volume 2 Issue 1 January 2020 Research Article
Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for
Identifying Children Aged 1 to 3 Years at Nutritional Risk
1 1,2 1 1 3 4
Beheshteh Olang *, Sayeh Hatefi , Farid Imanzadeh , Pejman Rohani , Farnaz Ehdayivand , Arezoo Rezazadeh ,
1 1 5 6 7 1
Fatemeh Abdollah Gorgi , Maryam Azizi , Fereshteh Fozouni , Zahra Abdollahi , Elham Talachian , Aliakbar Sayyari
8
and Agneta Yngve
1Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University
of Medical Sciences, Tehran, Iran
2Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3Supervisor of Family Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food
Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
5Supervisor of Nutrition of Deputy of Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
6Department of Nutrition, Ministry of Health and Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
7Pediatric Gastroenterology division Ali-Asghar Children’s Hospital, Iran University of Medical Sciences, Tehran, Iran
8Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and
Dietetics, Uppsala, Sweden
*Corresponding Author: Beheshteh Olang, Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research Institute
for Children's Health, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
E-mail: beheshteholang@gmail.com
Received: August 19, 2019; Published: December 10, 2019
Abstract
Background: Toddlers' life is an important period for growth and development. Nutritional deficiencies created during this period
are almost hard to compensate. This implies the need for timely, accurate and cost-effective screening of toddlers. Traditional meth-
ods of checking food intake are time consuming and expensive.
Objectives: Validate the NutriCHEQ questionnaire in assessment of the relevance of model and dietary intake of toddlers in Iran.
Methods: 155 children aged 12 to 36 months were randomly selected from health centers in the northen Tehran province. Their
parents were asked to register all of their foods and beverage intakes. Each day, a trained expert contacted them to get information
on food recalls, which were reviewed by Nutritionist 4. The NutriCHEQ questionnaire contained three parts; Part 1, Part 2 and Part 3.
Finally, using the above information and statistical methods including Pearson correlation coefficient, one-way ANOVA and Bonfer-
roni's test, for analyzing the data.
Results: The reliability of the first section was 0.62 and for the second section was 0.6. The mean NutriCHEQ scores for the first,
second sections and total, were 2.12 ± 1.23, 3.43 ± 1.98 and 5.55 ± 2. 51, respectively. According to the NutriCHEQ score, 14 children
(13%) were in the high risk group. There was a significant difference (p<0.5) between the risk groups in terms of percentage of
carbohydrate energy, protein energy, vitamin D, iron. In the second section, there was a significant difference (p<0.5) between the
groups in terms of daily intake of fiber.
Conclusion: The NutriCHEQ questionnaire seems to be a reliable and convenient tool for professionals and parents to identify chil-
dren aged 1 to 3 who are at nutritional risk. Keywords: Children, Malnutrition, Nutritional Screening, Outpatient, Validation
Keywords: NutriCHEQ; Questionnaire; Nutritional Risk
Introduction Malnutrition in this age group has increased significantly, and
The early years of life is an important period for growth, de- nutritional deficiencies created during this period are hardly com-
velopment and health in children [1-3]. The adequacy of nutrient pensable in the future [11]. Cognitive functions are associated with
intake in this sensitive period is a key determinant of health in the malnutrition, in particular lack of intake of iodine, iron, zinc, fo-
short and long term [3-7]. Early childhood is a period in which hab- late and vitamin B12 [4]. The toddler period is a time of dramatic
its and dietary preferences may be formed and the dietary habits changes in the physical and emotional development and is a key
that are created in this period may track into adulthood [8-10]. phase in the transition from breastfeeding to family food. In the
Citation: Beheshteh Olang., et al. “Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at
Nutritional Risk”. Acta Scientific Women's Health 2.1 (2020): 15-22.
Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at Nutritional Risk
16
second year of life, the growth rate is reduced compared with in- to 3 who were referred to a Mofid children's hospital were asked
fancy, while the need for nutrients remains high. One to two year to complete the questionnaire. After identifying some minor prob-
old children need more energy and nutrients per body weight, lems, the NutriCHEQ was slightly edited in order to be suitable for
which indicates that the energy and nutrient density should be the Iranian community. The edited questionnaire was evaluated by
high in toddler’s diet [12]. On the other hand, this age coincides a panel of specialists in the field (pediatricians and nutrition ex-
with the formation of a sense of independence, over confidence, perts in children's nutrition) and underwent a formal validation.
complaint of foods and fear of new food [6,13,14]. Studies show • Participants: A total of 155 children aged 12 to 36 months
that the current diet of toddlers is related to social status, especial- randomly selected from the children from health centers in
ly maternal education and in some cases inadequate [15,16] and the northern Tehran province were included in the study.
therefore, many children are at nutritional risk. • Study Design: The parents of these children were asked
to register all of their dietary foods, beverages and dietary
Generally, nutrient-rich foods are consumed to a lesser extent supplements with their amount for three consecutive days.
than the recommended dietary guidelines suggest, and high-cal- At the beginning of each day, a trained expert from the health
orie foods with low nutrient density are prevalent. For example, center contacted them to get food information recorded on
the UK National Diet and Nutrition Survey of 2008/09 showed the previous day. Parents did not receive any specific nu-
that 50% of children aged 1.5 to 3 years in four days of registered tritional advice before the study, every food record/recall
dietary intake, consumed high-calorie items with low nutrient about daily intake, was according to the parents of the chil-
content, such as meat products, fried potato, bakery products and dren in the study. The amount, type and name of all foods
sweetened drinks [13]. Foods rich in nutrients, such as fish, raw and beverages were recorded. Parents were asked to specify
vegetables and eggs were consumed by less than half of the same the amount of food by using units (eg, grams, ml), packaging
sample population. Similar patterns were observed in other coun- sizes or household measures (such as cups, teaspoons or ta-
tries, such as the United States and Australia [13]. With a high risk blespoons). The average nutrient intake was evaluated using
of a combination of malnutrition and environmental stress in some nutritional specific software (Nutritionist 4 version, Canada)
social strata, the path to a healthy development may be challenged in terms of macronutrient and micronutrient intakes. All par-
which can lead to a poor performance in school, reduced economic ents signed informed consent form. Sick children were not
opportunities and chronic health problems in adult life. When mal- included in the study if the child had an illness other than
nutrition and its consequences persist through the reproductive allergies or was on a diet or if the parent/caretaker did not
period and adulthood, it can affect the next generation and results sign the informed consent form.
in a vicious cycle of economic and health deprivation [5].
The NutriCHEQ questionnaire, which was answered by the
This emphasizes the need for timely, accurate and cost-effective mother or the caretaker on the last day, was collected and scored
screening of toddlers in terms of nutritional risk. This is normally by a trained expert from the health center, according to instruc-
done by comparing the food intake in these children with the di- tions provided by the original authors of the questionnaire.
etary guidelines. Traditional methods of checking food intake, such NutriCHEQ questionnaire
as recalling and recording food, is time consuming, expensive and The NutriCHEQ questionnaire contained three parts, the first
difficult. It is also difficult to compare the data extracted from these part of which was scored, consisting of two sections. The first sec-
two methods with dietary guidelines, which are based on food tion contained 4 questions and examined the iron and other key
groups. Using a Food Frequency Questionnaire (FFQ) is a cheaper, nutrients intake. The second section contained 7 questions and
faster, and more convenient method, and the results can be made investigated the child's nutritional balance. Possible answers to
comparable to food guidelines. However, a complicated question- each question were limited A, B, C. Answers in the "A" category are
naire can reduce family co-operation. Therefore, an appropriate appropriate or desirable (zero score); in“B” category are less than
nutrition assessment questionnaire for toddler diet should be ideal (score 1); and in "C" category are the potential causes for con-
short and simple and provide results based on food groups. Cur- cern / action (score 2). By collecting scores within each section, a
rent dietary questionnaires evaluate only a limited group of foods risk indicator for a toddler's nutritional status is obtained, which is
(such as oils or fruits and vegetables) and we have a limited set of designed for evaluation, while the combined scores for sections 1
Materials and Methods and 2 are generally ranked on all nutritional aspects. The maximum
The original NutriCHEQ questionnaire was carefully checked by achievable score is 22 score from sections 1 and 2. The second and
the program executives and colleagues and translated without any third parts were not scored and examined the risk factors associ-
changes. Then, parents of a small group of healthy children aged 1 ated with parental feeding patterns that affect the child's future
Citation: Beheshteh Olang., et al. “Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at
Nutritional Risk”. Acta Scientific Women's Health 2.1 (2020): 15-22.
Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at Nutritional Risk
nutritional status and provide a space for parents to address their 17
child's nutrition concerns. the score obtained from NutriCHEQ was used to determine whether a
higher score in NutriCHEQ is associated with lower nutrient density
Statistical analysis and/or higher prevalence of obesity/overweight or not (using one-
To measure the reliability of the first and the second section way ANOVA and Bonferroni's test).
of the NutriCHEQ questionnaire Cronbach's Alpha test was used. Results
To assess content validity and face validity, the questionnaire was In this study, 155 toddlers (1-3 years old) were studied and 84
distributed among experts and their views on the questions in the children (54.2%) were male. The mean age was 20.0 ± 6.7 months
questionnaire were considered and these validities confirmed by (range 12-36 months), weight 11.3 ± 1.9 kg (range 7.7-18 kg) and
the experts. To evaluate concurrent validity, the NutriCHEQ ques- height 83.6 ± 8.7 cm (range 71-102 cm). Demographic and anthro-
tionnaire was compared with the recall questionnaire, and the pometric characteristics of Iranian children aged 1 to 3 years old
Pearson correlation coefficient between the two questionnaires and their parents' educational status are summarized in Table 1.
was meseaured. Characteristics of the study population were ex- According to the WHO growth standard (weight for height), 16
pressed using descriptive statistics. NutriCHEQ's ability to assess children (10.3%) were underweight, 132 (85.2%) had normal
nutritional risk by comparing the child's score in NutriCHEQ and weight and 7 (4.5%) were overweight. There were no significant
data collected was calculated using two methods: 1) Correlation differences in the sex of children, percentile and Z-score of weight
test for assessing the relationship between points of questions to height and level of parental education between the three age
and NutriCHEQ sections with the average intake of nutrients us- groups. The mean of height and weight of children in the three age
ing Pearson correlation coefficient. 2) Children's quartile based on groups showed statistically significant difference (P <0.001).
Total population 1 year 2 years 3 years P
Number of participants (n) 155 48 58 49
Gender (%), male: female 84:71 23:25 35:23 26:23 0.423
Anthropometrics Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Weight (kg) 11.3 ± 1.9 10.3 ± 1.9 10.9 ± 1.2 12.8 ± 1.8 <0.001
Height (cm) 83.8 ± 6.7 78.1 ± 4.4 82.5 ± 3.7 90.9 ± 4.9 <0.001
Weight for Height z-scores -0.4 ± 1.3 -0.2 ± 1.4 -0.6 ± 0.9 -0.6 ± 1.4 0.181
Percentile 36.3 ± 31.3 42.2 ± 32.6 33.1 ± 27.3 34.3 ± 34.0 0.297
Weight for Height z-scores 0.119
Underweight (≥3rd centile) 15 (9.7%) 3 (6.3%) 4 (6.9%) 8 (16.3%)
Normal (>3rd to ≤96th centile) 135 (87.1%) 43 (89.6%) 54 (93.1%) 38 (77.6%)
Overweight (>97th centile) 5 (3.2%) 2 (4.2%) 0 (0%) 3 (6.1%)
WHO centiles (%) 0.100
Underweight (≥3rd centile) 16 (10.3%) 4 (8.3%) 4 (6.9%) 8 (16.3%)
Normal (>3rd to ≤96th centile) 132 (85.2%) 40 (83.3%) 54 (93.1%) 38 (77.6%)
Overweight (>97th centile) 7 (4.5%) 4 (8.3%) 0 (0%) 3 (6.1%)
Mother’s Education n (%) n (%) n (%) n (%) 0.490
Primary/Intermediate 5 (3%) 0 (0%) 3 (5%) 2 (4%)
Secondary 66 (43%) 19 (40%) 27 (47%) 20 (41%)
Tertiary 84 (54%) 29 (60%) 28 (48%) 27 (55%)
Father’s Education 0.129
Primary/Intermediate 5 (3%) 0 (0%) 3 (5%) 2 (4%)
Secondary 76 (49%) 19 (40%) 28 (48%) 29 (59%)
Tertiary 74 (48%) 29 (60%) 27 (47%) 18 (37%)
Table 1: Demographic and anthropometric characteristics of children aged 1 to 3 years old and their parents’ educational status.
Citation: Beheshteh Olang., et al. “Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at
Nutritional Risk”. Acta Scientific Women's Health 2.1 (2020): 15-22.
Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at Nutritional Risk
To measure the reliability of the first section of the NutriCHEQ 18
questionnaire, which mostly reviews the intake of iron and vitamin
D, Cronbach's Alpha test was used, and the reported alpha value
was 0.62. For the second section of the questionnaire, which mea-
sures the risk factors associated with the feeding pattern, the reli-
ability was reported 0.6, using the Cronbach's Alpha test. To assess
content validity and face validity, the questionnaire was distrib-
uted among experts and their views on the questions in the ques-
tionnaire were considered and these validities confirmed by the
experts. To evaluate concurrent validity, the NutriCHEQ question-
naire was compared with the recall questionnaire, and the Pearson
correlation coefficient between the two questionnaires reported Figure 2: Distribution of NutricheQ risk categories for
0.6, which indicated that the concurrent validity is relatively ap- Sections 2 in Iranian preschool children aged 1-3 years who
propriate. participated in the NutriCHEQ validation study.
The mean NutriCHEQ scores for the first section, second sec-
tiont and total, were 2.12 ± 1.23 (range 0-6), 3.43 ± 1.98 (range
0-11) and 5.55 ± 2. 51 (range 0-15), respectively. According to the
obtained NutriCHEQ score, in the first section, 49 children (32%)
were categorized as low risk (0-1 points), 68 children (55%) were
in the moderate risk group (2-3 points) and 20 children (13%)
were in the high risk group (4-8 points) (Figure 1). In the sec-
ond section, 52 children (34%) were categorized as low risk (0-2
points), 84 children (54%) were in the moderate risk group (3-5
points) and 19 children (12%) were in the high risk group (6-11
points) (Figure 2). In total, 28 children (18%) were in the low risk
group (0-3 points), 113 children (73%) in the moderate risk group
(4-8 points) and 14 children (9%) in the high risk group (9-15
points) (Figure 3). Figure 3: Distribution of NutriCHEQ risk categories for the
total NutriCHEQ scores (Sections 1 and 2) in Iranian preschool
children aged 1-3 years who participated in the
NutricheQ validation study.
The results of statistical analysis for assessing the existence of
a significant difference between the use of nutrients and micronu-
trients are summarized in Table 2. Since the scores of each section
are different to identify the risk group, the analysis was performed
separately for each section. Each analysis compared the average
consumption of any food that was extracted from a 3-day recall.
In the first section of the NutriCHEQ questionnaire, a statisti-
Figure 1: Distribution of NutricheQ risk categories for cally significant difference was found between the risk groups, in
Section 1 in Iranian preschool children aged 1-3 years who terms of percentage of carbohydrate energy (P = 023), protein (P
participated in the NutriCHEQ validation study. <0.001), protein energy content (P = 0.009), fat (P = 0.042), Folate
(P = 0.048), vitamin D (P <0.001), vitamin E (P <0.001), Iron (P
According to the score obtained from each section of NutriCHEQ = 0.001), Calcium (P <0.001), Potassium (P <0.001) and Zinc (P =
questionnaire, children were assigned to separate risk groups and 0.049). However, there was no significant difference between the
the average consumption of any food was determined individually, risk groups in terms of carbohydrate intake, energy intake from lip-
based on a 3-day recall. ids and intake of vitamin A (P> 0.05).
Citation: Beheshteh Olang., et al. “Assessment of Validity and Reliability of the NutriCHEQ Questionnaire for Identifying Children Aged 1 to 3 Years at
Nutritional Risk”. Acta Scientific Women's Health 2.1 (2020): 15-22.
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